This invention relates to blades and blade drive combinations for ophthalmic surgical procedures and more particularly to improved blades and blade holders for use in microkeratomes, and methods of making such blades.
A very widely adopted modern technique for correction of deficiencies in human vision is based on a procedure which modifies the optics of the cornea. In this procedure, generally termed laser in-situ keratomileusis (LASIK), a flap is cut in the cornea. The flap is lifted and the exposed area is impacted by a laser beam in a precision pattern to ablate or vaporize small target areas on the cornea in accordance with the needed correction. The flap is immediately returned into its position, where it stays in place without the use of stitches or sutures.
The instruments for making the cuts are called microkeratomes and comprise semiautomatic or automatic units for first suctioning the eye surface into stable position for the cutting blade, and then for slicing the blade through the cornea at the precise chosen depth. The actual surgical procedure is of short duration, presents low risk and involves minimal recovery time. Because of these factors earlier procedures for reshaping the cornea have largely been supplanted by the LASIK procedure, except where the LASIK procedure cannot be used for a particular optical correction.
The use of microkeratomes is generally regarded as having originated with Barraguer, based on publications dating from 1949, which initially used a manually driven device. While the subsequent history of development is relatively short, it has been intense, leading to a number of machines that are now in existence. All essentially employ a small thin cutting blade (e.g. about 0.01 inch in thickness) that has a cutting edge width of the order of one half inch (12.5 mm). The blade is held at a low angle to slice through the cornea at the selected depth. Even though the cutting edge of the blade is very sharp, it is reciprocated or oscillated from side to side during the advance through the cornea to facilitate the shearing action. In most machines, starting with those of Barraguer, this reciprocation is accomplished by an eccentric drive pin on the machine that engages a slot in a holder or driver attached to the blade. As the eccentric drive pin rotates during advance of the blade, it moves along the slot or groove, which is sized and angled so that transverse displacements of the eccentric pin introduces the reciprocating motion. The holder is attached permanently, or in a securely detachable manner, to the upper side of the cutting blade, and the slot is at an angle to the plane of the blade, which angle is determined by machine design. That is, the reciprocating pin lies, dependent upon system configuration, along an axis that may be close to or at a substantial angle relative to the horizontal.
The Barraguer design is shown in Hoffman U.S. Pat. No. 4,662,370, with other designs being shown in Ruiz U.S. Pat. No. 5,133,726, Krumeich U.S. Pat. No. 4,884,570, and Giraud et al. U.S. Pat. No. 5,342,378. The referenced patents position the blade at a relatively small acute angle relative to the cornea, with the reciprocating pin rotating about an axis at a substantially higher angle. In accordance with these teachings the blade is driven in a linear path through the cornea as the cut is made. To provide a microkeratome which drives the blade in an arc about the center of the eye, Hellenkamp in U.S. Pat. No. 6,051,009 uses a blade and holder combination, also in conjunction with an eccentric drive pin, but one that rotates about a substantially vertical axis. Thus the slot or groove in the blade holder is on the top surface of the holder, lying in a horizontal plane. The Hellenkamp machine design is such that, given the arcuate movement, the rear corners of a rectangular blade would interfere with other parts. To avoid this, the rear corners of the blade are simply eliminated, making the rear edge shorter than the front cutting edge of the blade. Apart from this geometrical difference, the blades of Hellenkamp and the different prior microkeratomes must meet the same basic requirements as to size, thinness, sharpness of blade edge, and the like.
Microkeratome blades are not per se fragile, in the ordinary sense of the term, but are so subject to minor flaws that they can be regarded as virtually unusable after any minor impact or deviation. The medical procedures involved, and the results sought, must be so controlled that a blade used in making an incision in one eye is typically not used again, because the blade tip has deteriorated merely from its brief engagement with corneal tissue. In further evidence of this criticality, some of the microkeratome machines include sensors for measuring frictional and other drag exerted on the vibratory mechanism. If the resistance is too high the drive might vibrate, affecting the cleanness of the incision. The drag of the cutting blade is a minor factor in this dynamic, but the use of such a measurement indicates the degree of uniformity that is involved.
Experience and studies have shown that a number of what may be called second order effects are of substantial significance to the uniformity of the corneal section, and therefore to the qualitative results of the surgery itself. For example, an article entitled “Independent Evaluation of Second Generation Suction Microkeratomes”, by Robert F. Hoffman, MD, et al., in Refractive and Corneal Surgery, Vol. 8, September/October 1992, pages 348-354, provides an analysis of three machines which were then current. All three machines were analyzed with respect to the accuracy of the thickness of the corneal flap, the smoothness of the corneal bed after the sectioning, and the appearance of irregularities in the corneal bed. Scanning electron micrographs, which provide high magnification images of the corneal bed, and high precision thickness measurement techniques were used to reveal deficiencies in each of three respects. The deficiencies were given in terms of “the accuracy of the resection diameter and thickness”, “the ultrastructure of the resected stromo surfaces”, and “the quality of the blades”. In addition it is known that the cleaner the cut the faster the healing process. The eccentric action used to induce reciprocating motion was found to produce a periodic nonuniformity called “chatter”, which was present in various degrees but always discernable. The vibratory motion imparted to the blade can also be understood to set up vibrations which propagate in different ways in the blade, and thus may give rise to resonances which cause deviations in the plane of the cut.
Nonetheless the requirements of the medical procedure dictate that each blade be handled individually for purposes of inspection, cleaning and final finishing. Even though the blade is honed and polished for maximum cutting efficiency, which is difficult to do, the blade itself is so thin that it may have imperfections, such as small bends or concavities that affect cutting of the corneal bed or lamellar flap. For example, a seemingly minor dip at the rear edge or in the interior body can be carried through to the cutting edge, affecting blade linearity. The more a blade must be handled during manufacture to assure flatness, smoothness and free of abrupt corners and edges other than the cutting tip, the greater the chance of this type of reduction of quality and uniformity.
What initially might appear to be a simple problem, in other words, has by such studies been revealed to involve much more complex and significant factors that affect both the optical correction and the efficacy of the healing process. Despite this understanding, basic blade and holder designs have remained largely unchanged and these problems are not known to have been addressed.